Late-Breaking: Greening the Urogynecology OR: Do Green ORs Have A Higher Infection Rate?

Objectives: The U.S. health care system has an enormous carbon footprint made worse by the production of single-use supplies, including surgical drapes and gowns. Emerging evidence suggests that smaller surgical fields (“green” draping) do not lead to higher infection rates, though a paucity of data exists in the field of gynecology specifically. The objective of this study was to compare the proportion of treatment for culture-proven urinary tract infection (UTI) within 2 weeks of operating room (OR) cystoscopy prior to and after a green draping protocol was implemented. Secondary outcomes included proportion of treatment of UTI irrespective of the availability of culture results and risk factors associated with postoperative UTI.

Methods: A pre-post implementation noninferiority study was performed from 2021 to 2023 in a urogynecology division at an academic medical center. The predetermined noninferiority limit was 7%. The green draping protocol eliminated the use of top drapes, leg drapes, and gowns; blue towels were permitted per surgeon's discretion. All cases of diagnostic cystoscopy and cystoscopy with Botox, hydrodistension, fulguration, periurethral bulking, pelvic trigger point injections, or other minor procedures were included; cases with concomitant urogynecology procedures were excluded. After 1/1/2022 only cases adhering to the green protocol were included. Treatment for UTI was defined as the prescription of antibiotics for symptoms of UTI confirmed with a positive urine culture. Data were analyzed using Fisher’s exact, Student’s t-tests, Mann-Whitney U, and noninferiority tests.

Results: The cohort included 120 pre-protocol and 120 green protocol cases. Pre-protocol patients were younger (52.5 vs 58.9 years, p=.009) and had higher rates of interstitial cystitis/bladder pain syndrome (IC/BPS) (44.5% vs 30.8%, p=.03) and pelvic pain (53.8% vs 34.2%, p=.003). Overall, UTI treatment was low in both groups. Treatment of culture-proven UTI (primary endpoint) in the green cohort did not meet the 7% margin of inferiority to the pre-protocol group (9 (7.5%) vs 7 (5.8%), p< .05). Treatment irrespective of urine culture availability was lower in the pre-protocol group (8 (6.7%) vs 14 (11.7%), p=.30) (Table). Of those in the total cohort with a UTI, 85.7% had either a history of recurrent UTI (rUTI) or IC/BPS. Odds of having a culture-proven UTI were higher with history of rUTI, IC/BPS, and older age (7.02, 4.34, and 1.21, respectively).

Conclusions: A green draping protocol is noninferior to standard draping with respect to rates of postoperative culture-positive UTIs. Although treatment of UTI irrespective of culture availability in the green cohort met the margin of inferiority, both cohorts exhibited infection rates consistent with the literature. As cystoscopy is performed in office settings without full sterile fields, clinicians may choose to use a smaller field in the OR to decrease the carbon footprint without compromising the quality of care.